Necrotizing Soft Tissue Infections: A Focused Review of Pathophysiology, Diagnosis, Operative Management, Antimicrobial Therapy, and Pediatrics.

Background: Necrotizing fasciitis is a major health problem throughout the world. The purpose of this review is to assist providers with the care of these patients through a better understanding of the pathophysiology and management options. Methods: This is a collaborative review of the literature between members of the Surgical Infection Society of North America and World Society of Emergency Surgery. Results: Necrotizing fasciitis continues to be difficult to manage with the mainstay being early diagnosis and surgical intervention. Recognition of at-risk populations assists with the initiation of treatment, thereby impacting outcomes. Conclusions: Although there are some additional treatment strategies available, surgical debridement and antimicrobial therapy are central to the successful eradication of the disease process.

Infecção puerperal / Puerperal infection

Em 1992, a Organização Mundial da Saúde (OMS) propôs a seguinte definição: Sepse puerperal é uma infecção do trato genital ocorrendo, em qualquer momento, entre a ruptura das membranas ou o trabalho e o 42º dia após o parto, no qual estão presentes dois ou mais dos seguintes eventos: • Dor pélvica; • Febre (temperatura oral de 38,5 °C ou superior em qualquer ocasião); • Corrimento vaginal anormal, por exemplo, presença de pus; • Cheiro anormal/mau cheiro do corrimento vaginal; • Atraso na redução do tamanho do útero (<2 cm/dia durante os primeiros oito dias). 1. O conceito de infecção puerperal deve ser complementado com o de morbidade febril puerperal, pela dificuldade de caracterizar a infecção que ocorre logo após o parto. 2. Outras definições que se fazem necessárias são: • Bacteremia: presença de bactérias na corrente sanguínea; • Sepse: síndrome clínica caracterizada pela resposta da hospedeira a um processo infeccioso, acompanhada de uma resposta inflamatória sistêmica; • Sepse grave: sepse associada à disfunção de um ou mais órgãos (sistema nervoso central, renal, pulmonar, hepática, cardíaca, coagulopatia, acidose metabólica); • Choque séptico: sepse com hipotensão refratária à ressuscitação volêmica. 3. A OMS incluiu o termo "infecção puerperal", pois hoje estão morrendo mulheres com infecções de outros locais do corpo.

Soft tissue infection after photoselective vaporization of the prostate: a life-threating complication.

Bladder outlet obstruction is a common aetiology of lower urinary tract symptoms in adult men and several treatment options are available. We report on a case of a 73-year-old man with a complicated soft tissue infection due to an urinoma after laser prostatectomy. He was treated by several surgical interventions and long-term antibiotic therapy.

Early-stage Management of Complex Wounds Using Negative Pressure Wound Therapy With Instillation and a Dressing With Through Holes.

INTRODUCTION: An early-stage decision clinicians often make in the management of complex wounds is which method of wound preparation will be appropriate for the patient. This decision can be affected by numerous wound and patient risk factors that present challenges and may make surgical debridement difficult in patients with complex wounds. Recently, negative pressure wound therapy with instillation and dwell time (NPWTi-d) using a novel reticulated open-cell foam dressing with through holes (ROCF-CC) was shown to aid in the loosening and removal of thick exudate and nonviable tissue from wounds. OBJECTIVE: The authors present their experiences of using NPWTi-d with ROCF-CC, along with rationales for wound care decisions. MATERIALS AND METHODS: Patients received antibiotics and surgical debridement when appropriate. Therapy selection and parameters were based on a decision-tree model for wound care management that takes into consideration patient and wound information. Most patients received NPWTi-d with ROCF-CC for a duration of 5 to 8 days; however, 1 patient received NPWTi-d with ROCF-CC for more than 30 days due to the wound extent and severity. Therapy consisted of instilling saline or quarter-strength sodium hypochlorite solution with dwell times of 3 to 10 minutes, followed by 2 hours or 3.5 hours of NPWT either at -100 mm Hg or -125 mm Hg. RESULTS: There were 6 patients (3 men, 3 women; average age, 58.5 years) treated. Wound types included 3 pressure ulcers, 1 necrotizing soft tissue infection, 1 perianal abscess, and 1 large abdominal wound. Patient comorbidities included obesity, type 2 diabetes, and radiation therapy. In all cases, progression of wound healing was observed with no complications. This method produced viable granulation tissue and wound bed preparation; however, patients were not followed to closure or grafting. CONCLUSIONS: These cases help support the use of NPWTi-d with ROCF-CC as a viable option for wound care providers in the early-stage management of complex wounds.

The roles of early surgery and comorbid conditions on outcomes of severe necrotizing soft-tissue infections.

PURPOSE: Severe necrotizing soft-tissue infections (NSTIs) require immediate early surgical treatment to avoid adverse outcomes. This study aims to determine the impact of early surgery and comorbid conditions on the outcomes of NSTIs. METHODS: A retrospective cohort study was performed on all subjects presenting with NSTI at an academic medical center between 2005 and 2016. Patients were identified based on ICD codes. Those under the age of 18 or with intraoperative findings not consistent with NSTI diagnosis were excluded. RESULTS: There were 115 patients with a confirmed diagnosis of NSTI with a mean age of 55 ± 18 years; 41% were females and 55% were diabetics. Thirty percent of patients underwent early surgery (< 6 h). There were no significant differences between groups in baseline characteristics. The late group (≥ 6 h) had prolonged hospital stay (38 vs. 23 days, p < 0.008) in comparison to the early group (< 6 h). With every 1 h delay in time to surgery, there is a 0.268 day increase in length of stay, adjusted for these other variables: alcohol abuse, number of debridements, peripheral vascular disease, previous infection and clinical necrosis. Mortality was 16.5%. Multivariable analysis revealed that alcohol abuse, peripheral vascular disease, diabetes, obesity, hypothyroidism, and presence of COPD were associated with an increase in mortality. CONCLUSIONS: Early surgical intervention in patients with severe necrotizing soft-tissue infections reduces length of hospital stay. Presence of comorbid conditions such as alcohol abuse, peripheral vascular disease, diabetes, obesity and hypothyroidism were associated with increased mortality.

Defect Reconstruction of an Infected Diabetic Foot Using Split- and Full-thickness Skin Grafts With Adjuvant Negative Pressure Wound Therapy: A Case Report and Review of the Literature.

INTRODUCTION: Any alteration or impairment to normal wound healing can result in the development of chronic wounds, which may lead to serious complications such as infection and loss of body fluid and proteins. Primary closure alone may not be sufficient to fulfill the criteria of successful defect reconstruction. Therefore, additional procedures such as skin grafting must be considered as an option. CASE REPORT: The case of a 43-year-old woman with diabetes who was admitted to the University Hospital Rebro (Zagreb, Croatia) due to an infected, nonhealing wound on her left foot. Skin grafts combined with negative pressure wound therapy (NPWT) before and after graft application improved wound healing in this patient. CONCLUSIONS: In this patient, the combination of skin grafts with NPWT before and after graft application reduced the comorbidities and complications often seen in the diabetic patient population. Herein, the authors utilized a quicker, cost-efficient, and safer technique of wound closure compared with traditional nonsurgical methods.

Survival and associated risk factors in patients with diabetes and amputations caused by infectious foot gangrene.

BACKGROUND: Infectious gangrene of the foot is a serious complication of diabetes that usually leads to a certain level of lower-extremity amputation (LEA). Nevertheless, the long-term survival and factors associated with mortality in such patients have yet to be elucidated. METHODS: A total of 157 patients with type 2 diabetes who received treatment for infectious foot gangrene at a major diabetic foot center in Taiwan from 2002 to 2009 were enrolled, of whom 90 had major LEAs (above the ankle) and 67 had minor LEAs (below the ankle). Clinical data during treatment were used for the analysis of survival and LEA, and survival was tracked after treatment until December 2012. RESULTS: Of the 157 patients, 109 died, with a median survival time of 3.12 years and 5-year survival rate of 40%. Age [hazard ratio 1.04 (95% confidence interval 1.01-1.06)], and major LEA [1.80 (1.05-3.09)] were independent factors associated with mortality. Patients with minor LEAs had a better median survival than those with major LEAs (5.5 and 1.9 years, respectively, P < 0.01). An abnormal ankle-brachial index was an independent risk factor [odds ratio 3.12 (95% CI 1.18-8.24)] for a poor outcome (major LEA) after adjusting for age, smoking status, hypertension, major adverse cardiac events, and renal function. CONCLUSIONS: Efforts to limit amputations below the ankle resulted in better survival of patients with infectious foot gangrene. An abnormal ankle-brachial index may guide physicians to make appropriate decisions with regards to the amputation level.

Treatment of Soft Tissue Filler Complications: Expert Consensus Recommendations.

BACKGROUND: Dermal fillers have been increasingly used in minimally invasive facial esthetic procedures. This widespread use has led to a rise in reports of associated complications. The aim of this expert consensus report is to describe potential adverse events associated with dermal fillers and to provide guidance on their treatment and avoidance. METHODS: A multidisciplinary group of experts in esthetic treatments convened to discuss the management of the complications associated with dermal fillers use. A search was performed for English, French, and Spanish language articles in MEDLINE, the Cochrane Database, and Google Scholar using the search terms "complications" OR "soft filler complications" OR "injectable complications" AND "dermal fillers" AND "Therapy". An initial document was drafted by the Coordinating Committee, and it was reviewed and modified by the experts, until a final text was agreed upon and validated. RESULTS: The panel addressed consensus recommendations about the classification of filler complications according to the time of onset and about the clinical management of different complications including bruising, swelling, edema, infections, lumps and bumps, skin discoloration, and biofilm formation. Special attention was paid to vascular compromise and retinal artery occlusion. CONCLUSIONS: Clinicians should be fully aware of the signs and symptoms related to complications and be prepared to confidently treat them. Establishing action protocols for emergencies, with agents readily available in the office, would reduce the severity of adverse outcomes associated with injection of hyaluronic acid fillers in the cosmetic setting. This document seeks to lay down a set of recommendations and to identify key issues that may be useful for clinicians who are starting to use dermal fillers. Additionally, this document provides a better understanding about the diagnoses and management of complications if they do occur. LEVEL OF EVIDENCE V: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Isolated serratus palsy etiology influences its long-term outcome.

HYPOTHESIS AND BACKGROUND: The cause of isolated serratus palsy is multifactorial, but evaluation of the mechanism of the injury indicates that the lesion to the long thoracic nerve is mechanical in origin in most cases. What is unknown, however, is how etiology influences its long-term outcome. We believed that overuse injuries may recover sooner and better than acute traumatic, infectious, or inflammatory injuries. METHODS: We determined the presumed etiology of isolated serratus palsy in 92 patients treated by brace or observation only and compared it with its long-term outcome after a mean follow-up of 18.1 years (range, 2.1-26.9) by measuring pain, range of motion, and winging of the scapula. RESULTS: Trauma preceded 22 (24%) of the cases, exertion 37 (40%), infection 14 (15%), and surgery/anesthesia 10 (11%). In 9 (10%) cases, no etiologic factor was evident. Serratus palsy preceded by infection recovered better than did cases with no infection, and those with palsy preceded by surgery/anesthesia had a poorer outcome than did those with no surgery (axilla, chest, or any other areas) or anesthesia. Those palsies caused by acute trauma or acute or chronic overuse/exertion had the same recovery course. DISCUSSION AND CONCLUSION: Etiology of isolated serratus palsy influenced long-term outcome less than we had expected. It seems, however, that palsies caused by infection recover better and those caused by surgery wherever in the body recover most poorly.

Correlation of Physical Exam Findings with Fever in Patients with Skin and Soft Tissue Infections.

INTRODUCTION: The objectives of this study were to determine the prevalence of fever in adult ED patients with skin and soft tissue infections (SSTI) and to determine which, if any, physical exam, radiograph and laboratory test findings were associated with fever. METHODS: We conducted a prospective, observational study at an urban county trauma center of adults who presented to the ED for evaluation of suspected SSTI. ED providers measured area of erythema and induration using a tape measure, and completed data sheets indicating comorbid conditions and the presence or absence of physical exam findings. Fever was defined as any recorded temperature ≥ 38°C during the first six hours of ED evaluation. RESULTS: Of the 734 patients enrolled, 96 (13.1%) had fever. Physical and laboratory exam findings associated with the presence of a fever in multivariable logistic regression were the area of erythema, particularly the largest quartile of area of erythema, 144 - 5,000 cm2, (odd ratio [OR] = 2.9; 95% confidence interval [CI] [1.6 - 5.2]) and leukocytosis (OR = 4.4, 95% CI [2.7 - 7.0]). Bullae, necrosis, streaks, adenopathy, and bone involvement on imaging were not associated with fever. CONCLUSION: Fever is uncommon in patients presenting to the ED for evaluation of suspected SSTI. Area of erythema and leukocytosis were associated with fever and should be considered in future decision rules for the evaluation and treatment of SSTI.

[Arterialized venous free flaps for resurfacing hand and finger defects]. / Freie, arterialisierte venöse Lappenplastiken zur Deckung an Hand und Fingern.

BACKGROUND: Soft tissue defects on the hand and on the fingers with exposed functional structures require a thin and sturdy closure. If skin grafts or local flaps are not possible the arterialized venous free flaps represent a good alternative. PATIENTS AND METHODS: This retrospective study included all arterialized venous free flaps used for hand and finger defects since 2005. We evaluated type and technique (for example antegrade vs. retrograde arterial inflow and the number of veins) and size of the flaps. Flap harvesting time was also examined. RESULTS: 11 venous flaps were used for resurfacing hand and finger defects. Most of them were retrogradely arterialized. 10 of 11 flaps healed uneventfully. Due to a thrombosis in an outflowing vein one flap was lost at the sixth postoperative day. Median size of the arterialized flaps was 6×4 cm and the median time for flap harvest was 38 (27-51) min. The donor site was primarily closed in 2 cases and in 9 cases with a skin graft. CONCLUSION: Arterialized venous free flaps represent a reliable and safe option for resurfacing hand and finger defects. Easy and fast harvesting due to the visible venous vascular system is an advantage. The flaps are thin, pliable and can be easily adjusted to the needs of the defect. Using conservative measures it is possible to control side effects like venous pooling, swelling and purplish discoloration. With arterialized venous free flaps early hand therapy is possible, in contrast to heterodigital and local flaps. In comparison to other free flaps it is not necessary to sacrifice an artery at the donor site.

[Treatment of patients with purulent wounds by using the original method of hydrodynamical drainage].

In this article the work of the Omsk State Medical Academy's department of general surgery is presented. The aim of study was to treat patients with purulent and necrotic wounds of soft tissue by using novel hydrodynamical drainaige. In this research 92 patients were taken part, who were inpatient treatment in the department of purulent surgery City Clinical Hospital No 1 named Kabanov A. N. 2010-2013 with purulent and necrotic wounds of soft tissue. Clinical, laboratory, cytological, bacteriological monitoring were conducted over the of wound process during the treatment. Assessment of the reliability of differences between the mean value of clinical indicators was with the calculation of the criterion t--Student, the method chi2 and Criterion Mann-Whitney U. The proposed method of treatment of purulent wound promotes fast the removal of necrotic tissue and pus in the first phase of the wound process that led to more rapid relief of symptoms of intoxication (fever, leukocytosis and common symptoms) at the patients of the basic group. Due to faster removal of necrotic tissue, reduction of common symptoms of intoxication at the patients of the basic group the transition from degenerative and inflammatory type of cystograms to regenerative occurred one or two days before than in the comparison group.

Soft tissue infections with atypical mycobacteria in two patients with inflammatory rheumatic diseases using TNF-inhibitors and/or leflunomide.

Infections of the soft tissues due to atypical mycobacteria are relatively uncommon. We describe two cases. A 61-year-old woman with rheumatoid arthritis (RA) who was treated with the combination of the TNF inhibitor etanercept (Enbrel) and leflunomide (Arava), developed paronychia and cellulitis of the index finger due to Mycobacterium chelonae/abscessus complex. The patient was successfully treated with clarithromycin and surgical debridement. A second case describes a 50-year-old man with ankylosing spondylitis, receiving infliximab (Remicade) and low dose corticosteroids, who developed a granulomatous infection of the right thumb and forearm due to Mycobacterium marinum.The patient was successfully treated with clarithromycin and ethambutol. The increased risk for subcutaneous mycobacterial infections in these cases are probably related to the DMARD treatment with a TNF-inhibitor and leflunomide.

Geographic distribution of community-acquired methicillin-resistant Staphylococcus aureus soft tissue infections.

PURPOSE: The goal of this study is to look at the geographic growth patterns of community-acquired methicillin-resistant Staphylococcus aureus (MRSA) infections in our local region and to determine if specific geographic areas are at increased risk. METHODS: After Institution Review Board approval (132603-3), a retrospective chart review was conducted of 614 patients who underwent incision and drainage of an abscess by a single pediatric surgical practice from January 2004 to December 2008. In addition, previously published data from 195 patients who underwent incision and drainage of an abscess from January 2000 to December 2003 were reviewed. RESULTS: The most commonly cultured organism found in the pediatric population undergoing incision and drainage was S aureus (n = 388), of which 258 (66%) were methicillin resistant. This is a 21% increase from the rate of MRSA cultures identified from 2000 to 2003. Geographic information system space-time analysis showed that a cluster of 14 MRSA cases was located within a 1.44-km radius between 2000 and 2003, and 5 separate clusters of more than 20 MRSA infection cases each were identified in 3 separate cities over the 8-year time span using geographic information system spatial analysis (P value = .001). CONCLUSION: Methicillin-resistant S aureus has now become the most prevalent organism isolated from cultures of community-acquired abscesses requiring incision and drainage in the pediatric population in our local region. Significant clustering of MRSA infections has appeared in several different cities within our geographic region.

Joint arthritis and soft-tissue problems of the hand.

The hand, by virtue of its position in space, complex anatomical composition, and characteristic biomechanical properties, is subject to a host of disease processes and traumatic injuries. This article reviews the presentation, evaluation, treatment, and outcomes of treatment in hand infections, high-pressure injection injuries, Dupuytren disease, and arthritis.

Necrotizing soft tissue infections in the intensive care unit.

Necrotizing soft tissue infection is a severe illness that is associated with significant morbidity and mortality. It is often caused by a wide spectrum of pathogens and is most frequently polymicrobial. Care for patients with necrotizing soft tissue infection requires a team approach with expertise from critical care, surgery, reconstructive surgery, and rehabilitation specialists. The early diagnosis of necrotizing soft tissue infection is challenging, but the keys to successful management of patients with necrotizing soft tissue infection are early recognition and complete surgical debridement. Early initiation of appropriate broad-spectrum antibiotic therapy must take into consideration the potential pathogens. Critical care management components such as the initial fluid resuscitation, end-organ support, pain management, nutrition support, and wound care are all important aspects of the care of patients with necrotizing soft tissue infection. Soft tissue reconstruction should take into account both functional and cosmetic outcome.

Outcome of necrotizing skin and soft tissue infections.

BACKGROUND: Management of necrotizing skin and soft tissue infections (nSSTI) remains difficult, and the mortality rate has been high. We hypothesized that management of nSSTI by an emergency general surgery (EGS) service would improve outcomes. METHODS: Retrospective review of EGS patients with idiopathic nSSTI and comparison with historical controls. Demographic, co-morbidity, laboratory, and surgical data were collected. Non-parametric statistical analysis was used to evaluate differences between survivors and non-survivors. Logistic regression analysis was performed to identify risk factors for the primary outcome measure of death. RESULTS: Fifty-two patients met the inclusion criteria, with five deaths (9.6%). The median time to the operating room (OR) was 8.6 h. The Acute Physiology and Chronic Health Evaluation (APACHE) II score, serum lactic acid concentration, and intensive care unit length of stay were significantly different for non-survivors. The APACHE II score was an independent predictor of death when controlling for age and time to OR. CONCLUSIONS: An EGS service was associated with shorter time to OR, which may improve the outcome. Physiologic derangement, as estimated by the APACHE II score, is predictive of death from nSSTI.

Hand infections following penetrating fish fins or bones injuries (FFBI): a large, hospital based, retrospective study.

BACKGROUND: The incidence of hand infections caused by penetrating fish fins or bones injuries (FFBI) is likely to increase following worldwide constant growth of fishery production and consumption. Because data on these infections are scarce, the purposes of this study were to describe their clinical characteristics and disease course, and to analyze risk factors for a complicated disease course. METHODS: We studied retrospectively all cases of hospitalized patients with hand infections following FFBI over the years 1999-2006 in a single medical center. Demographic data, underlying diseases, clinical characteristics and disease course were analyzed for each case. Univariate and multivariate analysis were used for analyzing risk factors for a complicated hospitalization course. RESULTS: There were 122 separate episodes of hand infections following FFBI among 116 patients, with a mean age (+/- SD) of 52 +/- 19.7. The majority of cases were women (51.6%), and they arrived significantly later to the hospital after injury. Predisposing conditions (diabetes mellitus, liver disease, rheumatologic disorder, malignancy or chronic steroid treatment) were present in 25% of cases. Most of the cases presented with cellulitis. Cultures of either blood or wound were obtained in approximately 1/3 of cases, and 40% of them yielded an isolate. Ceftazidime and doxycycline were administered to 68.8% and 96.7% of cases, respectively. Surgical debridement was performed in 34.4% of cases, but there was no case of death or limb amputation. The presence of fever (p = 0.0005) and a predisposing condition (p = 0.035) were independently correlated with a complicated hospitalization course. CONCLUSIONS: The overall prognosis in this largest cohort of hand infections following FFBI was favorable, but immune dysfunction carried a complicated course.

Hand manifestations of diabetes mellitus.

Diabetes mellitus is a relatively common condition and is frequently encountered in patients seen by hand surgeons. This review examines the known problems associated with diabetes, as well as some of the clinical findings noted in these patients, who often have multiple visits for hand conditions over time.

Community-acquired Klebsiella pneumoniae complicated skin and soft-tissue infections of extremities: emphasis on cirrhotic patients and gas formation.

BACKGROUND: Klebsiella pneumoniae was rarely reported to cause complicated skin and soft tissue infections (cSSTIs). Our study was to delineate clinical characteristics and outcome of cSSTIs involving extremities caused by K. pneumoniae. PATIENTS AND METHODS: Adult patients aged 16 years or more with community-acquired cSSTIs, which involved the extremities and were caused by four common aerobic pathogens at a medical center in southern Taiwan during a 54-month period, were reviewed. RESULTS: Of 76 cases enrolled, Staphylococcus aureus was the most common pathogen (52 cases, 68%), followed by K. pneumoniae (16, 21%), beta-hemolytic streptococci (5, 7%), and Escherichia coli (3, 4%). Forty-six (61%) had underlying conditions, and diabetes mellitus was most common among K. pneumoniae and non-K. pneumoniae groups (63% and 45%, respectively). Compared to patients with cSSTIs caused by other bacteria, those with K. pneumoniae cSSTIs were predominantly male, more often had liver cirrhosis, malignant neoplasm and alcoholism. In addition, they were more likely to have fever, shock, bacteremia, gas formation, pyomyositis, metastatic infections, as well as longer durations of hospitalization. Using multivariate analysis, liver cirrhosis (adjusted odds ratio [aOR] 12.5, 95% confidence interval [CI] 2.0-79.1, p = 0.007) and male gender (aOR 11.5, 95% CI 1.1-116.8, p = 0.039) were significantly associated with K. pneumoniae cSSTIs. CONCLUSIONS: We highlight the role of K. pneumoniae in Taiwanese patients with cSSTIs involving extremities, and its potential for gas and pus formation, and metastatic infections. Empiric antimicrobial coverage of K. pneumoniae and close monitoring of metastatic infections are mandatory for patients with risk factors.